Solo Practitioner (No Incorporation)This type of practice structure is when a doctor is not incorporated. In this case, the doctor does not have the personal asset protection advantage that a corporate shield has to offer. Being non-incorporated, if someone files a malpractice suit against the doctor, they will not only be after all his business assets (equipment, accounts receivables, checking/savings accounts, insurance coverage), they will also be able to easily attach claim to his personal assets (home, furniture, vehicles, savings accounts, checking accounts, stocks, bonds, etc.).

Obviously, practicing solo (unincorporated) is very risky. The average doctor will have three malpractice cases filed against him during his career. Are you going to leave all your assets exposed? I hope not. There is no sure thing when it comes to lawsuits, but a corporate shield is usually effective in protecting your personal assets from business related claims. Therefore, incorporating your business is strongly recommended.

PartnershipsWhat is your motive for seeking a partner?

The two main reasons people seek a partnership are:

1. Sharing the stress. Starting a new practice on your own is extremely stressful. However, if you choose a partnership, you are setting yourself up for even more stress when the partnership inevitably fails.

2. One doctor wants the use of another doctor’s money. Remember, the person who puts in most money will want—and demand—most of the control.

Do you really want a partner? Consider the following statistics:

• 70% of partnerships break up within two years. • 90% of partnerships end in divorce. • Partners never share the same passion, work ethics, work habits, management views, etc. • A divorce in business can be just as traumatic and expensive as one in marriage.

The break-up of your partnership will undeniably confirm that entering into a partnership was the most expensive mistake you ever made. If You Are Determined to Start a Practice with a Partner, Follow this RuleSign a partner separation settlement agreement before you start your practice. You need to be able to end the partnership in a non-threatening manner. Decide, in advance, who gets the account receivables, X-ray equipment, adjusting tables, therapy, who leaves the facility, etc.

Don’t fool yourself into thinking that you don’t need this kind of agreement because you’re going into practice with your best friend. There is a tremendous amount of truth and warning in the phrase “best friends make the worst enemies.” If you execute a partner separation settlement agreement in advance, your best friend will probably remain a friend. It’s like having a roll bar on your Jeep. You hope you’ll never need it but, if you do, you’ll be happy it’s there.

Five Reasons Why Partnerships Blow Up 1. One partner wants to build the practice faster, work harder, and practice more hours than the other partner. The other partner works less, but still wants to share the income fifty-fifty. It won’t work.

2. One partner hires a spouse or relative to work in the practice. How can the other partner say, “No.” This always causes problems.

3. One partner takes cash from the cash drawer; the other partner does not appreciate being “stolen” from.

4. One partner becomes disabled. The other partner covers his practice for six weeks to ninety days. Any longer and the partnership will end in a divorce.

5. One partner wants to gouge insurance companies; the other partner is ethical. The ethical DC will end the partnership.

Advantages of a Partnership The advantages of a partnership are sharing responsibilities, sharing expenses, and covering for each other.

Disadvantages of a Partnership A major disadvantage of a partnership is that almost all partners are considered equally liable for the other partner’s mistakes. Depending on the type of partnership, if your partner is sued for malpractice, you will also be sued. If one partner gets a bad reputation with insurance companies, the same brush will paint the other partner. If one partner is over-friendly with patients of the opposite sex, the other partner’s reputation will also be tarnished. There will also be arguments over money when one doctor is generating more income or contributing more toward the growth of the practice than the other.

Should you incorporate? Talk to your accountant—he’s the expert on your particular tax situation. As previously discussed, an advantage of having a corporation is that it usually limits your liability. If a creditor sues your corporation, they can go after the assets of your corporation, but probably will not be able to go after your personal assets. There are also a few possible tax advantages, i.e., you may be able to deduct your health insurance premiums, create a pension plan, buy your automobiles through your corporation, etc. However, it’s usually more expensive to run a corporation than it is to practice solo, and there’s definitely less flexibility of operation.

Three Types of Corporations 1. A Professional Corporation (PC) or Professional Association (PA). These corporations can only be owned by professionals. Most states that have PC or PA corporations require professionals to use these types of corporations.

2. An incorporation (Inc.) – If it’s legal to practice under an “Inc.” in your state, you may be able to hire MD’s as employees. Non-DC’s may be able to own a portion or all of the corporation.

3. A “Limited Liability” Corporation (LLC). This is a fairly new type of corporation in which your liability is usually limited to the amount of money you have invested in the corporation. Many attorneys prefer LLC’s because of their liability protection. However, most accountants don’t recommend LLC’s because of increased accounting expenses.

Again, check with your accountant to determine if you should incorporate and, if so, what type of corporation would best suit your needs.

When you’re through being an associate and are ready to start your own practice, hire a consultant who specializes in starting practices to guide you. Don’t think that you now have the experience necessary to start and build a new practice…you don’t! Yes, you’ve gained the experience of caring for patients and learned some good office procedures, but that’s not enough knowledge to start a successful new practice. You still have to learn how to find a great office location, acquire effective bank negotiating strategies and cost-cutting remodeling negotiations, as well as how to market a new practice, etc. It’s the lack of this specialized knowledge that dooms new practices, not the lack of knowledge regarding patient care.

Next in this series on “How To Start A Practice,” I’ll discuss whether or not you should start a practice by entering into an independent contract arrangement.

The major metals involved in producing visible radiologic changes are lead, phosphorus, and bismuth. Of these, lead is the most frequent, but lead intoxication is still a rare skeletal disorder.

Lead may be ingested, inhaled, or implanted. Clinical symptoms occur abruptly, with abdominal pain, encephalopathy, and paralysis. Radiologically, the most definitive signs are the linear, transverse densities at the metaphyses (lead lines). The deposition of lead may also precipitate remodeling abnormalities. Phosphorus and bismuth exhibit similar changes.

Workers involved in the polymerization of polyvinyl chloride (PVC) may develop a peculiar form of acroosteolysis.

Dr. Terry R. Yochum is a second generation chiropractor and a Cum Laude Graduate of National College of Chiropractic, where he subsequently completed his radiology residency. He is currently Director of the Rocky Mountain Chiropractic Radiological Center in Denver, Colorado, and Adjunct Professor of Radiology at the Southern California University of Health Sciences, as well as an instructor of skeletal radiology at the University of Colorado School of Medicine, Denver, CO. Dr. Yochum can be reached at 303-940-9400 or by e-mail at
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Dr. Chad J. Maolais a 1990 Magna Cum Laude Graduate of National College of Chiropractic. Dr. Maola is a Chiropractic Orthopedist and is available for post-graduate seminars. He may be reached at 303-690-8503 or e-mail
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This 12-year-old male patient presents with neck pain, following heading a soccer ball.

Discussion

Eosinophilic granuloma is the least severe but most common (60-80%) of all the histiocytoses.1,2 Peak incidence comes between the ages of 5 and 10 years and 75% of cases occur in individuals less than 20 years of age. Symptoms primarily are localized pain and swelling of less than 2 months’ duration. Eosinophilic granuloma typically lacks the systemic features of Hand-Schüller-Christian or Letter-Siwe disease. Occasionally, pathologic fracture will be the presenting problem. Vertebral involvement is characterized by pain and, in some cases, complicating myelopathy may ensue secondary to cord and nerve root compression. Temporal bone involvement may produce otitis media-like symptoms, and the diagnosis of eosinophilic granuloma should be suspected when patients with suspected otitis media do not respond to traditional medical treatment.1

More than 50% of cases involve the skull, mandible (25%), spine (6%), pelvis (20%), and ribs (7%). Of the long bones, the femur (15%), tibia and humerus (8%) are involved most often. The bones of the hands and feet are affected rarely.2 Monostotic presentations are three times more common than polyostotic presentations.2 Monostotic lesions progress to lesions elsewhere in 20% of cases.1 Pain may be the primary symptom and the diagnosis often requires histopathologic analysis of the lesions, as well as the detection of S-100 CD1 antigens on immunohisto-chemical analysis of the tissues.

Spine

More than 50% of cases involve the thoracic spine; 35%, the lumbar spine; and less than15%, the cervical spine.1 Solitary vertebral involvement is more common, though multiple levels are occasionally involved. With cervical involvement, C2 is the primary target in adults, whereas the middle cervicals are normally affected in children.1,2

The vertebral body is usually involved with relative sparing of the neural arch structures. In contrast, cases have been reported of lesions affecting the posterior arch and lateral masses in the absence of vertebral body involvement; however, this is rare. An osteolytic lesion is the expected radiographic appearance.1,2

Neural arch involvement, when present, destroys the internal matrix, but preserves the cortical outline, which has been described as a ghostly appearance. The most prominent feature in the lumbar and thoracic spine is pathologic fracture, with dramatic loss of vertebral height as thin as 2 mm, involving both the anterior and posterior vertebral body surfaces (vertebra plana, silver dollar vertebra, coin-on-edge vertebra).1 This is rare in the cervical spine. Areas of destruction within the centrum may be observed before collapse. A short-segment kyphosis usually accompanies thoracic vertebral involvement. Paravertebral swelling can be prominent and is more likely to be associated with increased risk to the cord. On CT examination, osteolytic destruction can be seen, which simulates aggressive neoplasm; occasionally a sequestrum may be visible.

Bracing is the treatment of choice, and surgical intervention is rarely necessary. Restoration of height with healing is to be expected in at least 90% of cases and can be rapid over 1 year. The majority of cases reconstitute to 48-95% of normal height, especially in patients under 15 years of age at the time of onset. Residual sclerosis and trabecular accentuation always remain. Rarely, interbody fusion may occur after radiotherapy and, occasionally, there is a bone-within-bone appearance. Healed lesions do not appear to increase the risk for long-term back disability in adulthood.

Dr. Terry R. Yochum is a second generation chiropractor and a Cum Laude Graduate of National College of Chiropractic, where he subsequently completed his radiology residency. He is currently Director of the Rocky Mountain Chiropractic Radiological Center in Denver, Colorado, and Adjunct Professor of Radiology at the Southern California University of Health Sciences, as well as an instructor of skeletal radiology at the University of Colorado School of Medicine, Denver, CO. Dr. Yochum can be reached at 303-940-9400 or by e-mail at
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Dr. Chad J. Maola is a 1990 Magna Cum Laude Graduate of National College of Chiropractic. Dr. Maola is a Chiropractic Orthopedist and is available for post-graduate seminars. He may be reached at 303-690-8503 or e-mail
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.

“Doctor, I’ve been worried about my hump. Will it get worse? Can you fix it?”

Unlike the better-known dowager’s hump, the upper thoracic hump (see photos and illustrations) is more common and is found in younger as well as older people.

Patients are concerned about their humps and are very motivated to get them fixed. They should be. Along with its unattractiveness, the hump affects the heart, lungs and thyroid.

Increased thoracic curve (hyperkyphosis) has even been linked to increased mortality. One research paper finds, “The hyperkyphotic posture was specifically associated with an increased rate of death due to heart disease.”1

The hump can also cause or contribute to hand, arm, shoulder, neck, lower back, sacrum and sciatica pain. Patients fear it is a harbinger to little-ol’-man/woman status, i.e. the dowager’s hump.

The classical dowager’s hump or dorsal kyphosis (forward curve in the mid and upper thoracic spine) is associated with old age and may involve wedged or triangular shaped vertebral bodies, compression fractures and osteoporosis. Undoubtedly, it is the end-stage of a chronic subluxation pattern and is probably related to the upper thoracic hump.

Subluxation patterns

Pattern: A consistent, characteristic form, style, or method, as:

A composite of traits or features characteristic of an individual or a group: one’s pattern of behavior.2

In medicine, a “syndrome” denotes a group of symptoms that characterize a disease condition. Chiropractic, being a vitalistic healing profession rather than disease and symptom oriented, refers to a group of subluxations as a pattern.

There are a few common patterns we can quickly locate (analyze) and correct (yes, correct) with Koren Specific Technique (KST). In addition to the hump pattern, there are the panic pattern, various cranial patterns, the femur head pattern and the upper cervical pattern.

What is the hump pattern?

A bump is usually easily palpated at the top of the thoracic spine or at the thoracic/cervical area. The head is often anterior to the shoulders, exposing the upper thoracic area. The body deposits fat over the exposed area, which has been referred to as the “hump pad.”3

The hump pattern causes loss of height and diminished lung capacity. Diminished lung capacity may not be noticed until the pattern is corrected and you tell the patient to inhale. (“I didn’t realize it, but now I can take a deep breath.”).

In illustration “A” on the far left, the woman’s head sits evenly over her shoulders; this is “normal” posture. In illustration “B”, her head is anterior to her shoulders and, over time, the hump may develop fatty tissue to protect the “exposed” area.

Because of her anterior head carriage the trapezius muscles are often tight and there is greater stress on the mid-thoracic spine and her lower back and sacrum.

When the hump is corrected…

When the hump pattern is corrected or adjusted, patients often experience immediate improvement in posture, balance, breathing and loss of inflammation along the anterior ribs. A greater overall sense of relaxation and well-being is often noticed as deep subluxation stress releases.

The goal of chiropractic care is not to correct the hump per se, but to correct the subluxations associated with the hump (the hump pattern). Once the subluxations are corrected and the segments are no longer fixated, the body is better able to restore a healthy posture.

For many, the hump may not appear much different at first; however, for some people, the hump may dramatically reduce within a few days and may disappear within weeks. Others, depending upon age and lifestyle, may take longer. But, as long as the hump remains unsubluxated, it will be healing.

Fixing the hump pattern

The key to a proper correction is specificity: knowing exactly what is out of alignment and the direction of the misalignment (listing). This permits you to use a minimal amount of force/energy/information to correct the subluxation. Corrections will also be more long lasting.

Note: With KST hump pattern adjusting, the patient is standing or sitting.

2. Ribs: 1st, 2nd and 3rd anterior ribs are usually inferior on the right and superior on left. This is important. The reason the hump persists, even after vertebrae adjustments, is because the ribs are locked. There may be inflammation and sensitivity over the anterior ribs when they are challenged.

3. Other thoracics: A mid thoracic vertebrae (usually T-7 to T-9 inferior) is involved. It may be rotated left or right. The ribs are usually inferior on one side and superior on the other side.

Note: Hump pattern patients often have lumbar and/or sacral problems/subluxations. This may be compensation for the anterior head carriage.

Slight variations

Some hump patterns have complications (oh, no!) and, unless corrected, the hump will not release. Here they are:

1. T-1 and T-2 counter-rotation: In addition to T-1 and T-2, superiority, T-1 and T-2 may be counter-rotated, meaning that T-1 is rotated left, while T-2 is rotated right or vice versa (challenge the spinous processes). In some cases, counter-rotation can cause severe nerve impingement and pain, numbness and paresthesias and weakness in the shoulders, arms, wrists, hands and fingers.

2. Transverse process (TP) and rib involvement: Occasionally, you’ll find T-1 and T-2 tilt. The transverse processes (TPs) may be anterior/superior on one side and posterior/inferior on the other. The rib articulations can be involved, causing brachial plexus problems. It isn’t easy to adjust the TP and ribs from the inferior and posterior (unless you’d like to do some surgery), so contact the superior/anterior side.

3. Thoracic discs: On occasion you’ll find thoracic disc subluxations. C-7/T-1, T-1/T-2 or T-2/T-3 discs may be subluxated on the left or right side. Adjust, using the ArthroStim™.

4. Sternum and clavicles: On rare occasions, a patient may have the sternum and/or clavicles out of alignment. This is often as a result of trauma.

Adjustment/correction

Finally! Let’s fix that hump. Koren Specific Technique (KST) is a quick and easy method of analyzing and correcting any part of the body. It will quickly tell you if there is a hump pattern. After you determine the listings involved, we recommend you use the ArthroStim™ adjusting instrument to correct the involved segments.

The ArthroStim™ is a “toggle in a bottle.” I set it at 12 taps per second. In a pinch, a hand-held adjusting instrument may work. You can also use a thumb toggle (á la DNFT) but, in my experience, nothing corrects subluxations as easily as an ArthroStim™.

1. Correcting the upper thoracics: T-1 and T-2 are adjusted contacting the spinous or the lamina pedicle junction superior to inferior (S to I). T-3 is adjusted inferior to superior (I to S). If there is counter-rotation of T-1 and T-2 (i.e., one goes left, one goes right), it must be corrected and contact is usually on the spinous processes.

2. Correcting the ribs: This is very important. If the ribs are not released, the hump will not release and the upper thoracics will re-subluxate. The ribs are adjusted at their anterior. Contact is just lateral to the sternocostal junction on both sides. Line of drive is usually I to S on the right and S to I on the left. Use the sleeve with the narrow fork with the ArthroStim™. The ribs usually correct very easily but, be gentle, because they may be inflamed from years of subluxations.

3. Correcting disc subluxations: To locate a disc subluxation in KST, we use the negative finger (2nd or index). The procedure is as follows: Touch the area where the disc is located (between the vertebrae) and the body will tell you by the occipital drop or other biofeedback mechanism (i.e., muscle goes weak, reactive leg goes short) if the disc is subluxated. Adjustment is in the direction the negative finger is pointing; the negative finger “points” to the subluxation.

4. Fixing the lower thoracic(s): Usually T-7, T-8 or T-9, etc., is adjusted I to S. Adjust L to R or R to L if there is rotation.

5. Fixing the thoracic transverse process/rib articulation: Adjust the transverse process (TP) I to S on the high side and A to P on the anterior side. If there’s counter-rotation, either side may be out.

Will I need to correct the hump pattern on every visit?

KST adjustments usually hold for a long time. However, everyone is different and patients with severe hump patterns should be checked, at least initially, on every visit. You’ll find a re-adjustment is rarely needed.

Dowager’s Hump

Can KST procedures help dowager’s hump? Since the dowager’s hump (DH) kyphosis is due to compression fractures, unlike the upper thoracic hump, it will most likely never return to normal shape. However, people with DH don’t have to live in pain or get worse. When their subluxation patterns are corrected, the nervous system will function better. This will promote decreased pain and other symptoms, while promoting overall healing.

This is in contrast to the medical approach which is exercise, osteoporosis medications and a procedure called vertebroplasty or kyphoplasty, wherein a radiologist injects a cement into the porous sections of the fractured vertebra to stabilize the fracture, strengthen and raise the vertebral body to normal height.

KST adjustments offer a safer alternative.

Dr. Tedd Koren is the developer of Koren Specific Technique, a quick and easy way to locate and correct subluxations anywhere in the body. For information on KST seminars, go to www.teddkorenseminars.com or call 800-537-3001.

History: This 60-year-old male patient presents with acute lower thoracic pain after a fall while skiing. Axial flexion compression force occurred during this fall. The radiographic examination demonstrates how many compression fractures? Are these compression fractures benign or malignant?

DISCUSSION

Compression fractures of the lumbar spine are the result of a combination of truncal flexion and axial compression. The extent of the vertebral compression and degree of comminution are dependent upon the severity of the force applied and the relative strength of the vertebra. In the aging and geriatric patient with osteoporosis, compression fractures are quite common. The most common segmental levels to develop compression fractures are T12, L1 and L2.1,2

The Step Defect. Since the anterior aspect of the vertebral body is under the greatest stress, the first bony injury to occur is a buckling of the anterior cortex, usually near the superior vertebral endplate. This sign is best seen on the lateral view as a sharp step off of the anterosuperior vertebral margin along the smooth concave edge of the vertebral body. In subtle compression fractures, the “step” defect may be the only radiographic sign of fracture. Anatomically, the actual step off deformity represents the anteriorly displaced corner of the superior vertebral cortex. As the superior endplate is compressed in flexion, a sliding forward of the vertebral endplate occurs, creating this roentgen sign.1

Wedge Deformity. In most compression fractures, an anterior depression of the vertebral body occurs, creating a triangular wedge shape. The posterior vertebral height remains uncompromised, differentiating a traumatic fracture from a pathological fracture. This wedging may create angular kyphosis in the adjacent area. It has been estimated that a 20 percent or greater loss in anterior height is required before the deformity is readily apparent on conventional lateral radiographs of the spine.1

Linear White Band of Condensation (Zone of Impaction). Occasionally, a band of radiopacity may be seen just below the vertebral endplate that has been fractured. The radiopaque band represents the early site of bone impaction following a forceful flexion injury where the bones are driven together. Callus formation adds to the density of the radiopaque band later, in the healing stage of the fracture injury. This radiographic sign is striking when present; however, it is an unreliable sign, since it is not present as often as might be expected. Its presence, however, denotes a fracture of recent origin (less than 2 months’ duration).1,3

Disruption in the Vertebral Endplate. A sharp disruption in the fractured vertebral endplate may be seen with spinal compression fracture. This may be difficult to perceive on plain films and tomography provides the definitive means to identification. The edges of the disruption are often jagged and irregular.1,3

Paraspinal Edema. In cases of extensive trauma, unilateral or bilateral paraspinal masses may occur which represent hemorrhage. These are best seen in the thoracic spine on the anteroposterior projection, but may occur adjacent to the lumbar spine, creating asymmetrical densities or bulges in the psoas margins.1,3

Determining an Old versus a New Compression Fracture

Since the wedge shape deformity of the vertebral body persists after the compression fracture heals, additional roentgen signs are necessary to evaluate the time status of a compression fracture. The presence of a “step” defect and the white band of condensation are signs of an active or current fracture (less than 2 months old). These two roentgen signs will vanish once the fracture totally heals, which may be as long as 3 months in the adult spine.

When the question of presence or recent origin of the fracture arises, a radionuclide bone scan may be helpful. Such scans are positive (hot) with recent fractures undergoing active repair. These scans may stay positive (hot or warm) for as long as 18 months to 2 years following injury. This complicates the evaluation of a patient who has been injured previously (within 2 years). A bone scan may not prove helpful in this type of presentation.1,2,3 Additionally, MRI scans are the most accurate way of determining whether a fracture is old or new. Bone marrow edema will be present in recent fractures of 6 weeks or less duration and is more accurate than a bone scan to determine the chronology of a compression fracture anywhere in the spine.

Dr. Terry R. Yochum is a second generation chiropractor and a Cum Laude Graduate of the National College of Chiropractic, where he subsequently completed his radiology residency. He is currently Director of the Rocky Mountain Chiropractic Radiological Center in Denver, Colorado, and Adjunct Professor of Radiology at the Southern California University of Health Sciences, as well as an instructor of skeletal radiology at the University of Colorado School of Medicine, Denver, CO. Dr. Yochum can be reached at 303-940-9400 or by e-mail at
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